Gastro and Renal

8/10/2019 Gastro and Renal

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The Gastrointestinal and Renal Systems


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Viscera: internal organs in the abdominal

cavity.Can be divided into:

Solid viscera: is the viscera that maintain a

characteristic shape (ex. Liver, spleen, kidneys,ovaries).

Hollow viscera: its shape depends on the

contents (ex. Stomach, gallbladder, smallintestine, colon, bladder).


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For descriptive purposes, the abdomen is often

divided by imaginary lines crossing at the

umbilicus, forming the right upper quadrant(RUQ), right lower quadrant (RLQ), left upper

quadrant (LUQ), and left lower quadrant (LLQ).

Terms to know:*Epigastric-area

between the costalmargins.*Umbilical- areaaround umbilicus*Suprapubic- areaabove the pubic bone


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RUQ:

ascending colon,

duodenum,

gallbladder, rt kidney,

liver,

head of the pancreas

transverse colon, rt uretra

LUQ:

descending colon,

lt kidney,

body and tail of pancreas, spleen,

stomach,

transverse colon,

lt ureter.

RLQ:

appendix,

ascending colon, cecum,

rectum,

bladder,

overy, uterus, and fallopian

tube or prostate and spermic

cord, rt uretra

LLQ:

bladder,

descending colon, overy,

uterus, and fallopian tube or

prostate and spermic cord,

small intestin,

sigmoid colon,

lt ureter


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Note that the liver fills most of the RUQ and

extend over the midclavicular line.

Gallbladder is locatedunder the posteriorsurface of the liver.

Small intestine is locatedin all four quadrants.


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Spleen is located on the posterolateral wall of theabdominal cavity under the diaphragm. It lies obliquely & its width extends from the 9th11th

rib about 7cm. Not palpable normally.


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Aorta is located at left ofmidline in the upper part ofabdomen; bifurcates into the Rt

& Lt renal arteries then commoniliac arteries opposite 4thlumbarvertebra; Aortic pulsationseasily palpable in the upperanterior wall.

Rt & Lt iliac arteries become thefemoral arteries in the groin area.Their pulsations are palpable aswell.

Pancreas- soft, lobulated glandlocated behind the stomach;stretches obliquely across theLUQ.


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Kidneys are bean shaped & located posterior to

the abdominal contents;

Lt kidney lies at the 11th& 12thrib; Rt kidney is 1-2 cm lower than the Lt kidney &

may be sometimes palpable.


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The costovertebral angle: the angle formed by the

lower border of the 12th rib

and the transverse processes of the upper lumbar

vertebrae (for kidney tenderness).

*Bladder may be palpated in the lower midline (above

the symphysis pubis) when it is distended.


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Subjective Data

Concerning symptoms of the abdomen are:

Abdominal pain Indigestion, nausea, vomiting

Loss of appetite, early satiety

Dysphagia, odynophagia (pain with swallowing)

Change in bowel function Diarrhea, constipation

Jaundice

*Gastrointestinal disorders may be divided into lower and

upper problems.


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Categories of abdominal pain:

Visceral pain:

Occurs when hollow abdominal organs such as the

intestine or biliary tree contract unusually forcefully or

are distended or stretched. Solid organs such as the liver can also become painful

when their capsules are stretched.

Visceral pain may be difficult to localize. It is typically

palpable near the midline at levels that vary according to

the structure involved.


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Visceral pain varies in quality and may be

gnawing, burning, cramping, or aching.

When it becomes severe, it may be associated

with sweating, pallor, nausea, vomiting, and

restlessness.

Visceral periumbilical pain may signify early

acute appendicitis from distention of an inflamed

appendix. It gradually changes to parietal pain in

the right lower quadrant from inflammation of the

adjacent parietal peritoneum.


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Parietal pain:

originates from inflammation in the parietal

peritoneum.

It is a usually more severe than visceral pain andmore precisely localized.

It is increased by movement or coughing.

Patients with this type of pain usually prefer to lie

still.

Referred pain:

Is felt in more distant sites, which are innervated at

approximately the same spinal levels as the disorderedstructures.

Develops as the initial pain becomes more intense.

May be felt superficially or deeply and is usually well

localized.


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Dyspepsia: is defined as chronic or recurrent discomfort or pain

centered in the upper abdomen.

Discomfort: is defined as a subjective negative feeling that isnonpainful. It can include various symptoms such as bloating, nausea,

upper abdominal fullness, and heartburn.

Heartburn: is a rising retrosternal burning pain or discomfort. It istypically aggravated by food.

GERD: Gastroesophageal reflux disease.

Dysphagia: difficulty swallowing.

Odynophagia:pain with swallowing.


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Hematemesis:blood with vomit.

Melena: black terry stool.

Hemtochezia: stool that is red.

Regurgitation: raising gastric content, because of

the problems with sphincter (without vomiting).

Steatorrhea:presence of excessive fat in the stool.

What are normal characteristics of the vomit?

Give example of abnormal characteristics of thestool.

What is constipation?


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Concerning symptoms of the abdomen are:

Suprapubic pain Dysuria, urgency, or frequency

Polyuria, nocturia

Urinary incontinence

Hematouria

Kidney or flank pain

Ureteral colic


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Suprapubic pain may be related to bladder dysfunctions such as

bladder infection it is dull and pressure like.

Dysuria:pain with urination, or difficult urination

Urgency: immediate desire to urinate.

Frequency: frequent going to the bathroom, the volume of theurine may be large or small.

Polyuria: increase in urine volume (more than 3 liters pay day).

Urinary incontinence: involuntary loss of urine.

Hematuria:blood in urine, may be gross or microscopic.


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kidney pain: On the side of the body between upper

abdomen and the back.

May radiate toward umbilicus.

Visceral, dull, steady.

Ureteral colic

Originate at the costovertebral angle

Radiate around the trunk into the lower

quadrant of abdomen or to the thigh.

Is severe and colicky.

Kidney pain versus ureteral colic:


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Objective Data

Tips for Enhance Examination of the Abdomen

Check that the patient has an empty bladder.

Make the patient comfortable in the supine position, check that

he is relaxed.

Ask the patient to keep the arms at the sides or folded across the

chest.

With palpation, ask the patient to point to any areas of pain so

you can examine these areas last.

Warm your hands and stethoscope.

Approach the patient calmly and avoid quick, unexpectedmovements.

Begin with inspection, then auscultation, percussion, and

palpation.


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Inspection

Contour: shape of the abdomen.


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Symmetry: any visible masses, bulging.

Describe the location and size.

A herniaoccurs when an organ pushes through anopening in the muscle or tissue that holds it in place.


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The masses may be

related to tumors orenlargements.

Above: enlarged spleen


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Scars:

describe scares if any; location, size,

symmetry (traumatic or from surgery).

Kocher: open cholecystectomy,

mcBurneys: appendectomy,

Pfannenstiel: for gynecological procedures,

small incision; laparoscopy.


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Striae: stretch marks. Silver striae: old, pink-purple:

new. Most common in pregnant women and obese.


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The umbilicus: midline, inverted, no signs of

inflammation or hernia.

Skin: smooth, even no scar or lesion (redness, jaundice

,striae , moles, scars)

Dilated veins: a few veins may be visible normally.

Pulsation or movements: peristalsis (slow and oblique

across abdomen), respiration, pulsation of the aorta

(epigastric area). Are more visible in thin people.


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Auscultation

Describe bowel motility. The auscultation is performed before percussion and

palpation because they can altered the frequency of

the bowel sounds.

Normal: high pitch sound, gurgling, irregular 5-30time /min.

Must listen 5 minutes to say absent.

Check over the aorta, renal arteries, and iliac arteries.

Normal: No Bruit

Listen over liver and spleen for friction rub.


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A peritoneal friction rub

produced by friction between roughened peritoneal

surfaces, for example from inflammation or tumor. heard as a creaking or grating noise during respiration.


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Percussion

To assess the amount of gas

in the abdomen, to identify

solid or fluid-filled masses,

to estimate the size of liver

or spleen.

Percuss the abdomen in 4

quadrants to assessdistribution of tympany and

dullness.

General Tympany.


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Percuss the liver

- to determine the Liver span: 6-12 cm in tall male;

mean 10.5 cm in men and 7 cm in women. Measure the height of the liver in the Rt. MCL.

Percuss from up to down until note changes from

resonance to dullness. Mark the spot.


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Find abdominal tympany and percuss up until

note changes to dullness. Mark the spot.

Normal : at the right costal margin.

Scratch Test:


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Scratch Test:

Define the liver border in distended abdominal or

muscles tense.

Place stethoscope over the liver.

Scratch with one fingernail over the abdomen starting in

the RLQ.

Move up toward the liver.

Normal: sound becomes magnified in the border of theliver.


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Percuss the spleen: Percuss from 9th. To 11th. ICS behind

the Midaxillary Line.

Normal: dullness not wider than 7cm. Techniques to detect splenomegally:

1) Percuss the left lower anterior chest wall.


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2) Check for a splenic percussion sign.

Percuss the lowest ICS in the Lt anterior Axillary Line.

Ask the pt to breath deeply.

Normal: tympany remains through full inspiration.


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Percuss the kidney:

Place one of your hands in the costovertebral

angle and strike it with the ulnar surface of your

fist. Look of tenderness.

Palpation


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Palpation

To detect the size, location & consistency of

organs. To identify masses, abdominal tenderness,and muscular resistance.

Begin with light palpation (1 cm depth) in

rotatery motion, check in all abdomen. Perform deep palpation (5-8 cm), forabdominal masses.


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If you identify a mass note the following:

Locationsize

Shape

Consistency (soft ,firm, hard)

Surface (smooth, nodular).

Mobility ( movement during respiration).

Pulsatility

Tenderness


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Assess for peritoneal inflammation:

Especially when there is muscular spasm.

Ask patient to cough and ask if there was a pain

and where.

Palpate gently the tender area.


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Palpate the liver:

Lt. hand under the pts back parallel 11th.-12th. Ribs Left up to support the abdomen

Place Rt. Hand on the RUQ.

Push deep down and under the edge of the right costal

margin in the midclavicular line

Ask pt to take deep breath

Normal: if palpable at all, soft, sharp, & regular liver

edge with a smooth surface. The normal liver may beslightly tender. (firm: Jarvis)

If cannot fill it try hooking technique.


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Hooking technique:

Stand at the pts shoulders

Swivel your body to the Rt.Hook your fingers over the costal margin from

above


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Palpate the spleen:

Reach your lt. hand over the abdomen and behind

the lt. 11th.-12th.ribs

Left for support

Place Rt. Hand obliquely on the LUQ with fingers

pointing toward lt axilla. To the rib margin. Push deep down under the costal margin

Ask the pt to breath deeply

Normal: not palpable


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Palpate the Rt kidney:

Place the 2 hands together in a duck-bill position at

the pts Rt. Flank

Press firmly while asking pt to breath deeply

Normal: not palpable or feeing of the lower pole of the

Rt kidney as:

Round smooth mass


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Palpate the Lt kidney:

Reach your lt. hand across the abdomen and

behind the lt. flank Push your Rt. hand deep while asking pt to

breath deeply

Normal: not palpable.

P l t th t


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Palpate the aorta:

Palpate the aortic pulsation slightly left to midline

in the upper abdomen using your thumb and

fingers.

Normal: 1-4 cm wide and pulsates in an

anterior direction

Differ by the thickness of abdominal wall and

anteroposterior diameter of the abdomen.


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Palpate the bladder:

When palpating the bladder it should be distended.

Located above symphysis pubis.

The dome of it feels smooth and round.

Use percussion to check the dullness and

determine how high it rises.


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Special procedures:

1) ascites:

fluid wave For differentiate ascites from gaseous.

Standing on right side . Place the person's hand on his abdomen in the

midline (to stop transition of wave through fat). Place your left hand on the person's right flank. With your right hand give the left flank firm

strike if ascites is present the blow will generatea fluid wave through the abdomen and you willfeel a distinct tap on your left hand.


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Shifting Dullness/ ascites.


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g

In supine person ,ascitic fluid setting by gravity

into the flank displacing the airfilled bowel

upward.


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2) Appendicitis:

A)Rebound tenderness: press down your fingers

firmly and slowly and then withdraw themquickly. (in the RLQ)

Positive test if there is pain with finger withdraw.

The pain is caused by rapid movement of inflamedperitoneum.

B) Rovsing sign: an indication of acute appendicitis

in which pressure on the LLQ of the abdomencauses pain in the RLQ.


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C) Psoas sign (Iliopsoas muscle pain): put your

hand above the patients Rt knee and ask the pt to

raise that thigh against your hand. Or , passively

extending the thigh of a patient lying on his side

with knees extended.


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3) Acute cholecystitis:


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check for Murphy sign: a test for gallbladder disease in

which the patient is asked to inhale while the examiner's

fingers are hooked under the liver border at the bottom ofthe rib cage.

The inspiration causes the gallbladder to descend onto the

fingers, producing pain if the gallbladder is inflamed.

Deep inspiration can be very much limited.

Note that a positive Murphy sign may

also indicate the inflammation in liver.

Gastro and Renal

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